Abstract
The medical term phimosis has been in use since antiquity, but in
contrast to the imprecise definition of the term that is characteristic of
nineteenth-century and some controversial modern medical writing, Greek
and Roman medical writers imbued it with a clinically precise definition.
Using the tools of the history of medicine, an analysis of the medical
writings of antiquity reveals that phimosis was defined exclusively as a
rare, inflammatory or cicatricial stricture of the preputial orifice
consequent to a true pathological condition rather than a disease process
in itself. Putative associations between phimosis and diseases such as
urinary tract infections or cancer were not made in antiquity and are
reflections of modern, geographically isolated social anxieties. The
modern European scientific conceptualisation of phimosis, however,
represents a return to the precise terminology and conservative
therapeutic approach characteristic of Greek and Roman medicine.

Since the nineteenth century, medical writers have argued for the
existence of a complex and broadly defined disease construct to which they
have attached the ancient Greek word phimosis. In this context, phimosis
has been conceived of as a morphological deviation from a mythical penile
norm. Phimosis has, accordingly, been described as a foreskin that is "too
long" (hypertrophic phimosis), a foreskin whose orifice is not as
expandable as the foreskin of most adults (often called "true" phimosis),
or a foreskin that has not yet completed the developmental process of
physiological detachment from the glans (congenital phimosis). Rather than
a symptom of disease, phimosis has been classified as a disease sui
generis as well as a cause of disease, and as such, for nearly 200 years,
presumably responsible physicians, writing in leading medical journals and
textbooks have further claimed that the results of their research
'prove' that phimosis is the cause of such diseases as cancer of the male
and female reproductive organs, venereal disease, malnutrition, epilepsy,
hydrocephalus, insanity, idiocy, masturbation, heart disease,
homosexuality, deafness, dumbness, urinary tract infections, criminality,
and death, to name but a few. The drive to cure and prevent phimosis,
thus, has been presented as a surgical solution to the most pressing
social and moral problems [15].

The European medical concept of phimosis, however, has made a significant
departure from its nineteenth-century roots and from the current ideology
of American medicine, which still clings to nineteenth-century notions in
this respect. The vanguard of European medical experts no longer conceive
of phimosis as disease or as a cause of disease. Phimosis is now defined
as a stricture of the preputial orifice caused by lichen sclerosus et
atrophicus (LSA), also known as balanitis xerotica obliterans (BXO), a
rare, dermatological condition of unknown aetiology. In Britain, Rickwood
et al. have successfully argued that the definition of phimosis should be
divested of any notions of preputial non-retractability, physiological
balanopreputial attachment, or preputial length [19]. The new definition
of "true phimosis" refers to a condition where "the tip of the foreskin is
scarred and indurated and has the histological features of Balanitis
xerotica obliterans" [20]. More recently, Rickwood has refined this to the
formulas: "Phimosis = BXO", and "No BXO = No Phimosis" [21]. In the
historical context, the contemporary European refinement of the definition
of phimosis represents a return to an earlier definition of the term, one
that is found in the classic medical writings of Greek and Roman
antiquity.

Phimosis in antiquity

The word phimosis is derived from the Greek. For this reason,
medical
writers in the nineteenth century asserted that phimosis, as they defined
it, was recognised by the Greeks as a genuine penile defect. An analysis
of the corpus of ancient medical literature, however, demonstrates that
the nineteenth-century conceptualisation of phimosis does not correspond
with the Greek and Roman definition of the term.

Throughout the greater portion of the span of antiquity, phimosis
as a
medical term did not exist. Indeed, Greek physicians of the classical era
were evidently uninterested in the foreskin from a medical perspective.
Significantly, the word phimosis does not appear in the Hippocratic corpus
of the fifth century BC. Reference to the foreskin as a distinct part of
the penis, however, is characteristic of the corpus. One such reference is
found in the Hippocratic aphorism that states:

When a bone, cartilage, sinew, the slender part of the jaw, or the
acroposthion is severed, the part neither grows nor unites [13].

Here we meet the useful Greek word acroposthion, which designates
the
visually defining, tapered, fleshy, nipple-like portion of the foreskin
that advances beyond the terminus of the underlying glans penis. The
acroposthion, especially in early youth, can run to impressive
lengths.
Distinguished from the acroposthion is the posthe,
which is the portion of
the foreskin that merely enfolds the glans penis, beginning at the coronal
sulcus. While it is not possible to make a definitive interpretation of
the above-cited Hippocratic aphorism, one might surmise that the allusion
to the severing of the acroposthion confirms that the originator of this
aphorism was aware of the foreskin-despoiling blood rituals peculiar to
some of the Semitic tribes inhabiting those regions that lay south-east of
Greek-inhabited lands.

As demonstrated by their visual art, the Greeks highly esteemed the
foreskin as a defining feature of the male body. Indeed, Galen speaks of
the foreskin as a brilliantly useful adornment. [10]. It is not
surprising, then, that half a millennium would pass before the word
phimosis entered the medical lexicon. Although it makes its first
appearance in the medical writings of the Roman era, writers first used
the term phimosis loosely to indicate a condition of being
constricted,
irrespective of the part afflicted. For instance, Galen [14], Heliodorus
[12], and Andromachus [1] used the term to refer to inflammatory
strictures of the anus or the eyelid, but not the foreskin.

In his Materia Medica, the Greek physician Dioscorides of Anazarbus, who
flourished under the reigns of Claudius and Nero (41-68 AD), mentioned
briefly that a concoction of the juice of the leaves of the herb
cotyledon
and wine would "soften constriction of the genitals, help inflammation,
erysipelas, chilblain, and when plastered over, help scrofula and sore
throat" [8]. The original Greek wording does not specify what part of the
genitals of what sex Dioscorides recommends as the target for the healing
powers of this herb. Furthermore, rather than use the word phimosis,
he
uses the etymologically related term phimos, which, in this case,
could,
with equal validity, refer to an imperforate anus or a urethral stricture
of either sex. Still, the historically portentous association had now been
made between the genitals and the idea of stricture.

Even if Dioscorides did not make the association in terms of the foreskin,
one or more of his coeval compatriots must have, for Aulus Cornelius
Celsus, who in all probability lived during the reign of Emperor Tiberius
(14-37 AD), says that they did. In his great work, De Medicina, Celsus reports:

On the other hand, if the glans has become so covered that it cannot be
bared, a lesion which the Greeks call phimosis, it must be opened out,
which is done as follows: underneath the foreskin is to be divided from
its free margin in a straight line back as far as the frenum, and thus the
skin above is relaxed and can be retracted. But if this is not successful,
either on account of constriction or of hardness of the skin, a triangular
piece of the foreskin is cut out from underneath, having its apex at the
frenum, and its base at the edge of the prepuce. Then lint dressing and
other medicaments to induce healing are put on. But it is necessary that
the patient should lie up until the wound heals, for walking rubs the
wound and makes it foul [5].

The first surgical treatment that Celsus describes is a ventral slit, a
minor, tissue-sparing procedure that would have imposed a fairly minimal
cosmetic defect. The second procedure, being a variation on the first,
involves the removal of a small amount of sclerotic tissue. Here again,
the ventral site of the incision would largely preserve cosmesis and
preputial mechanical function.

Elsewhere, Celsus provides a more detailed exposition of his concept of
preputial pathology, without, it must be emphasised, using the word
phimosis. In this instance, he stresses the abnormal induration of the
preputial tissue as the primary diagnostic key:

So then when the penis swells up owing to inflammation, and the foreskin
cannot be drawn back, or conversely drawn forwards, the place should be
fomented freely with hot water. But when the glans is covered up, hot
water should be injected, between it and the foreskin, by means of an ear
syringe. If the foreskin is thus softened and rendered thinner, and yields
when drawn upon, the rest of the treatment is more speedy. If the swelling
goes on, either lentil meal or horehound or olive leaves, boiled in wine,
is to be laid on, to each of which, whilst being pounded up, a little
honey is to be added; and the penis is to be bandaged upwards to the
belly. That is required in the treatment of all its disorders; and the
patient ought to keep quiet and abstain from food, and drink water just so
much as is justified by thirst. On the next day fomentations with water
must again be applied in the same way, and even force should be tried as
to whether the foreskin will yield; if it does not give way, the foreskin
is to be notched at its margin with a scalpel. For when sanies has flowed
out, this part will become thinner, and the foreskin the more easily drawn
upon. But whether the foreskin is made to yield by this procedure, or
whether it has at no time proved resistant, ulcerations will be found,
either in the ulterior part of the foreskin, or in the glans, or behind
this in the penis, and these ulcerations must of necessity be either clean
or dry or moist and purulent [6].

Celsus continues this passage with advice on diet, rest, and the
application of fomentations. Given the strict emphasis on cankerous
ulcerations, it is obvious that Celsus' concept of phimosis is that of a
pathological inflammation of the foreskin as a complication of canker. The
notching of the inflamed foreskin, in order to release the purulent
discharge, indicates that a true pathological condition is at work. In
contrast to the nineteenth-century medical conception of phimosis, Celsus
does not define phimosis as a "redundant", "tight", or "adherent"
foreskin. For Celsus, phimosis is a diagnostic description of the effects
on the foreskin caused by a real pathological condition, which, in the
post-bacteriological era, we might recognise as being of likely microbial
origin. Of special relevance is the first description of phimosis as an
induration of the foreskin, which neatly matches the modern European
medical understanding of the effects of LSA (i.e. BXO) on the foreskin.

The second known use of the word phimosis is found in the
extant writings
of the Greek physician Antyllus, who lived in the second century AD. The
writings of Antyllus enjoyed wide currency and were directly copied into
the encyclopaedic medical compilation of Oribasus, from which the
following passages are drawn, and Paulus Ægineta [18].
Proceeding where
Celsus left off, Antyllus further refines the medical conception of
phimosis to include reference to inelastic scar tissue and pathological
granulations as the cause of symptomatic preputial nonretractability. The
cure that he proposes entails a series of incisions in the scar tissue in
order to expand it and allow the foreskin to function properly.

On phimosisThere are two kinds of phimosis: in one case, sometimes the foreskin
covers the glans and cannot be pulled back; in the other case, the
foreskin is retracted but cannot be returned over the glans. This second
type is specifically called paraphimosis. The first type is the result of
a scar that has formed on the foreskin, or on a thick granulation in this
region. The second type is especially a result of inflammations of the
genitals, when, the foreskin being retracted, the glans is swollen and
holds the foreskin back. Thus, in the first kind of phimosis, we perform
the following operation: after having placed the patient in a convenient
position, we pull the foreskin forward and fasten little clips to the
extremity of this organ, which we have the assistants hold, advising them
to distend and open the foreskin as much as possible. If the stricture is
caused by a scar, we make three or four equally spaced straight incisions
in the inner fold of the prepuce with a lancet or a sharp instrument.
These incisions are only made in the inner fold of the foreskin, for, in
the part of the foreskin that covers the glans, it is double layered. We
thus incise the inner fold of the foreskin, for, in this way, after having
incised the cicatricial loop, we can retract the foreskin. If the phimosis
is caused by a thick granulation on the inner aspect of the foreskin, we
make all the incisions in this luxuriant flesh, we retract the foreskin,
and we scrape out the thick granulations between the incisions. This done,
we cover the whole glans with a lead tube, which we wrap with dried paper.
In this way, we prevent the foreskin, which has been returned over the
glans, from forming new adherences, since this last part is surrounded by
the tube. We maintain the foreskin in a state of dilatation, with the aid
of the lead and the paper that envelopes it. If the paper is soaked, it
will expand and dilate the skin even more [3].

The thematic and lexicographic connection that Antyllus draws between
phimosis and paraphimosis underscores the importance of the existence of
an inflammatory process implicit in a diagnosis of phimosis.

In a separate chapter, Antyllus describes a condition in which the
previously retractable foreskin becomes adhered to the glans because of
ulcerations of either part. The recommended cure entails freeing the
adhesions. Antyllus is careful to avoid calling this condition phimosis,
and instead calls it simply "adherence of the foreskin".

On adherence of the foreskin to the glansWhen either the glans, the foreskin, or both organs simultaneously are the
site of an ulceration, an adherence is established. Retracting the
foreskin as far as possible, one should free the adhesions with the sharp
edge of a scalpel, while endeavouring especially to separate rigorously
the glans from the part of the foreskin to which it is adherent. If this
is difficult, however, it is better to leave a little part of the glans
attached to the foreskin rather than do the opposite, for the foreskin,
being thin, is easily pierced. After having freed the adherences, one
places a thin cloth soaked in cold water between the glans and the
foreskin in order to prevent the formation of new adherences [4].

Although in the nineteenth century it was common to use the word
phimosis
to denote, among other things, both the pathological, ulcerative
balanopreputial adhesions of adult suffering the dermatological effects of
sexually transmitted diseases and the natural physiological
balanopreputial attachment characteristic of youth, Antyllus makes no such
error, restricting the term phimosis to inflammatory nonretractability of
the foreskin rather than pathological balanopreputial adherence. Neither
Antyllus nor any other Greek writer confused the developmental,
physiological, and transitory balanopreputial attachment of the juvenile
penis with pathological adhesions. As such, the strict definition of the
word phimosis was maintained.

One common misuse of the word phimosis by nineteenth-century
and some
modern medical writers concerns the length of the foreskin. Penises were
and are frequently diagnosed with phimosis because the foreskin has
arbitrarily been determined to be "too long", "redundant", or
"hypertrophic". The Greeks, however, recognised no such disease. In
antiquity, the problem was not having too much foreskin, but having too
little. Consequently, classical medical writers were concerned with a
deformity called lipodermus, a condition in which the foreskin was
not long enough to cover the glans penis completely.
Galen [11], Soranus [23],
Dioscorides [9], and Antyllus [2], among others, published lengthy
descriptions of lipodermus and made detailed recommendations for its
correction. Greek medical writers also devoted considerable space to
surgical and non-surgical methods of foreskin restoration following
posthectomy [22].

The wealth of classical medical writing devoted to the correction of
lipodermus and posthectomy, when considered against the relative paucity
of writing on phimosis as defined by medical writers in antiquity, lends
strength to the argument that inflammatory or cicatricial stricture of the
preputial orifice was a rare and unusual urological condition.

Conclusions

In contrast to the nineteenth-century conceptualisation of phimosis,
which
is predicated upon an alleged universality and defined purely in terms of
a misunderstanding of preputial development and a biased view of penile
morphology, the conception of phimosis in antiquity was based on rarity
and on clinically verifiable histological pathology. The
nineteenth-century conceptualisation of phimosis was predicated on the
pathologisation of the three defining characteristics of the juvenile
foreskin: physiological preputial nonretractability; physiological
balanopreputial attachment, and generous length of the acroposthion.
These
pathologised, but not genuinely pathological, attributes were believed to
be diseases in and of themselves that could cause other diseases. In
antiquity, phimosis was defined strictly as a stricture of the preputial
orifice that had been caused by a genuine dermatological disease process.
The differing conceptualisations of phimosis provide an important example
of how nineteenth-century medicine pathologised the natural body and
sought justification and legitimacy for this culturally motivated process
by asserting a false analogy with classical medical concepts.

Finally, the current European concept of phimosis can be viewed as a
return to the original classical understanding of phimosis as a symptom of
clinically verifiable pathological conditions. This change is reflected in
the increasing move towards establishing evidence-based pharmacological
treatments [16, 17] and tissue-preserving surgeries [7] that, like their
classical antecedents, are focused on treating underlying pathology,
maintaining foreskin function, and preserving natural cosmesis.